ACS Health Policy Scholar reports on the value of small acts

Editor’s note: SreyRam Kuy, MD, MHS, FACS, is a practicing general surgeon who serves as Associate Chief of Staff at the Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, TX, where she works to improve health care quality and patient safety. Dr. Kuy is a 2016 recipient of the American College of Surgeons (ACS) Health Policy Scholarship, and the 2017 recipient of the ACS Mary Edwards Walker Inspiring Women in Surgery Award.

A frail woman, about 70 years old, sat on the hard cot, wearing an oversized donated gray sweater and huddling beneath the thin white blanket and the glaring lights of the Baton Rouge, LA, stadium that had been converted into a flood shelter. Earlier, she had been gesturing wildly, but now she was sitting still, dejected and mute. The flood shelter volunteers thought she might have dementia or psychosis but couldn’t tell because she didn’t speak English. They asked me to assess if she had dementia, and to help triage if she needed to be transferred to the special needs medical shelter at the Louisiana State University amphitheater across town.

A shelter in Louisiana during the historic flooding in summer 2016

I had just entered the stadium, doing a walk-through to assess the infrastructure of the on-site medical team in my new role as the Chief Medical Officer (CMO) for Medicaid, Louisiana Department of Health. Just a few weeks earlier, I had finished my training at the Brandeis University Heller School of Management, Waltham, MA, Executive Leadership Program as the recipient of the ACS Health Policy Scholarship in General Surgery. Little did I know that the lessons learned about leadership, crisis management, and stakeholder engagement would be put to use so soon.

In the program, Stewart Altman, PhD, and Jon Chilingerian, PhD, described how Carlos Ghosn revolutionized the auto industry, shared stories about working in presidential administrations ranging from those of John F. Kennedy to Barack Obama, and described how they negotiated success in seemingly impossible situations. Now, I found myself thrust into the epicenter of Louisiana’s Great Flood of 2016. We worked around the clock to mobilize a systematic response to the flooding that wreaked $20 billion in damage to the state.

The woman stood up hopefully as I approached, but when she realized I didn’t speak her language, she dejectedly shook her head. Fortunately, I had a surgical colleague who spoke her language and helped from hundreds of miles away, translating by phone. She passed our rudimentary mini mental exam and did not appear to have dementia.

However, as it turned out, she didn’t know her address, had no belongings beyond the donated sweats she wore, had been separated from her son during the flooding, and did not know his phone number or whereabouts. She slumped her shoulders into the blanket as if to shrink herself into oblivion. I was of limited use, so I just held her. I barely clear five feet tall while wearing heels, but that day I towered over this frail, tiny woman. She felt so small and fragile in my arms, ready to shatter into dust if I held any tighter. I felt powerless, but she looked up, and it seemed as though something as simple as the human touch had bridged what words could not communicate. I was reminded of what another tiny woman, Mother Teresa, once said: “Not all of us can do great things. But we can do small things with great love.”

The impact of caring

If anything, I’m a testament to what people can do with great love. At one time, I had no home, lived in a shelter, and was clothed from a charity bin. It wasn’t a flood shelter in Louisiana, but a refugee camp on the other side of the world. It was 1980, and my family had just escaped from Cambodia. We sought shelter in the border camps. But two weeks later, an errant rocket-propelled grenade ripped through our tent, lacerating my scalp, tearing off the lower part of my left ear, and blasting a crater in my mom’s belly as she tried to shield me with her body. A volunteer Red Cross surgeon operated on both of us, saving our lives. I never learned his name, but he inspired me to become a surgeon. Since I was a small child, I’ve had an idealized image of this fearless superhuman hero who had saved my life. I’ve wondered how this nameless hero felt, knowing that he was making such an impact on so many lives.

The truth is, he probably didn’t know that. Since becoming a surgeon myself, I’ve crossed paths with several American physicians, a surgeon, an anesthesiologist, and an emergency medicine physician who had spent time working in those same Cambodian refugee camps in the late 1970s and early 1980s, treating survivors of the genocide known as the killing fields. I don’t know if they personally took care of me, among the hundreds of thousands of other refugees sheltered in the border camps; nonetheless, I’ve thanked them for their service to humanity. But what has always surprised me is that they thanked me.

As one of those volunteer physicians said, “I didn’t know if what I did even made any difference.” There was so much need and so little equipment. At times, it was a matter of triaging who among the injured would get surgery, who had a likely fatal injury, or which sick child would get the ventilator when so few ventilators were in the refugee camp. It was overwhelming, knowing that there were not enough providers to care for all of the wounded and sick. And even if they stopped the bleeding or sutured a laceration, they weren’t sure what substantial difference had been made when 2 million Cambodians had already died during the genocide, the infrastructure of the country had been razed to the ground, and hundreds of thousands of individuals were arriving in the refugee camps malnourished, diseased, and traumatized. One physician told me, “After I returned to the States, I wondered what happened to those children. What future did they have? I didn’t know if I’d even made any difference.” Then he smiled at me, and said, “Now I know. Thank you.”

Having lived in shelters and known the generosity of a stranger’s compassion, I’ve experienced both sides of the shelter cot, as a refugee and as a provider. And I often have felt that what we do is too small, too inconsequential, too futile. But the truth is, it does make a difference. We just might not get to see the results for years, if ever. But it matters.

Rebuilding physical and mental health

In Baton Rouge, the flood waters have receded and the streets are dry. But don’t be fooled. The need is tremendous. Months later, as I drove down the residential streets, both sides of the roads were lined with stacks of debris from gutted homes: flood-soaked mattresses, splintered wooden tables, ruined loveseats, tossed out like broken dreams. In the shelters that I visited, the need persisted as families tried to reconnect and rebuild, often without cars to drive or homes to return to.

Also great are the mental health needs. What we’ve learned from previous disasters, ranging from Katrina to Sandy, is that the mental health effects often occur late and linger. In hard cents and dollars, the economic loss of the Louisiana Floods was staggering. It’s been estimated that Louisiana’s flood losses total $20.7 billion, with 110,000 homes damaged. Our challenge was tremendous as we surveyed the ravages of the flood, but we must never think that our efforts are futile.

The first time I went to the flood shelters, I met a young physician who had been working medical triage for three days straight. As we spoke, she started crying. She wasn’t crying because she was exhausted. She was crying as she described the circumstances of the flood victims. I heard this same heartfelt emotion from a tough Texas emergency medicine physician deployed to the Louisiana shelters, a large national guardsman patrolling the stadium, and a shy nursing student who had traveled across the state to volunteer at the shelter. The compassion in action came from all corners of the country, from all faiths and all shades of skin color. And they gave until it hurt. To paraphrase that tiny woman who knew the power of small acts, Mother Teresa, “This is the meaning of love, to give until it hurts.”

What the floods showed me is that this is a country with courage—where people from all races, faiths, and political beliefs come to together when our country hurts. And, in my journey from a refugee camp to the flood shelters, I have seen that this is the heart of America. We come together to do something with great love, to give until it hurts.

Putting new skills to use

The ACS Health Policy Scholarship gave me the skills to start a new position as Louisiana Medicaid’s Chief Medical Officer (CMO), giving me strategies, techniques, and knowledge that I have used every single day, as well as a network of close friends and colleagues on whom I can call (including my surgeon translator, Quyen Chu, MD, FACS). As CMO for Louisiana Medicaid, I had the opportunity to tackle the opioid crisis, develop quality metrics to improve health care delivery and improve health information technology adoption among providers in the state.

Because of my work at Medicaid, I had the good fortune to be selected as a Presidential Leadership Scholar, where I had the opportunity to learn about leadership from Presidents George W. Bush and William J. Clinton.

The Presidential Leadership Scholars program enabled me to successfully implement opioid initiatives and policies, develop a naloxone standing order to enable the lay public to save lives during an overdose, and support the creation and passage of legislation limiting inappropriate opioid prescribing. At the commencement ceremony for the Presidential Leadership Scholars program, I had the opportunity to be the keynote speaker. I spoke about what a privilege it is to live in the U.S., and have the freedom to serve our communities. I am grateful to live in a country where everyone truly deserves a chance, and given that chance, we can take the risk and see what life yields.

Following my tenure as CMO at Medicaid, I now have the privilege of serving our country’s heroes as associate chief of staff at the Michael E. DeBakey VA Medical Center, the most complex VA hospital in the nation, which houses 5,000 staff and the busiest emergency department and operating rooms in the country.

My journey in health care policy began in a small classroom at Brandeis University. I cannot overstate how much this program has benefited me. I am truly indebted to the ACS for this life-changing experience, which enabled me to grow as a surgeon and as a leader. However, my journey as a healer began as the recipient of the compassion and kindness of one surgeon in a refugee camp. Whether that was a small act to him, among the thousands of lives that he likely saved, it was not small to me. There is great value in small acts.